From coast to coast, cities and states are implementing ambitious plans to expand government-managed health coverage to more Americans.

Just this week, leading Democrats from California, Washington, and New York have unveiled proposals to expand public coverage to those who are currently not eligible or can not afford to register.

California Governor Gavin Newsom calling the federal government has room for maneuver to allow its state to create a single payer system. Washington Governor Jay Inslee is to propose a "public option": a state-run health plan that competes with private insurers. And New York Mayor Bill de Blasio pumps 100 million dollars every year in public hospitals in the city so that the uninsured can consult a primary care physician at an affordable price.

These state and city plans are probably the best way for Democrats to extend public coverage while President Trump remains in office. Although it is true that congressional Democrats are aligning themselves more and more behind a Medicare platform for all – the intention to hold the first hearings of the Chamber on politics this year – it is also true that these efforts are futile upon arrival with a Republican Senate and Presidency.

Instead, cities and states offer a testing ground for health policy ideas that the party may want to take at the national level if they regain control of the Senate or presidency in 2020. President Obama, for example, used Massachusetts' innovative health coverage expansion in 2006 as a framework for structuring the Affordable Care Act.

The proposals show that health care remains a motivational topic for Democrats. The party is not entirely satisfied with the Affordable Care Act, which extends coverage to millions of Americans but also leaves 11.7% uninsured population. There is a desire to go even further – and many different ideas on how to do it.

Single payer, public option, charitable assistance: three ways for Democrats to extend public coverage

Democrats share the goal of expanding coverage for health insurance, but they are proposing different policies to achieve it.

In Washington State, Governor Jay Inslee proposes a "public option": a state-run, non-profit health plan to compete with private insurers.

Senators vigorously debated the inclusion of a public option in the Affordable Care Act as a means of increasing market competition and reducing premium costs. But the public option was eventually dropped by Obamacare as it became apparent that there was not enough support for moderate senators.

Inslee is now trying to revive this policy at the state level – and if it does, Washington will be the first state to implement a public option. Inslee offers a state-run health plan that would reimburse doctors and hospitals for Medicare rates (which tend to be lower than prices paid by private plans and therefore a way to reduce insurance premiums).

Inslee is working with the state legislature, under the current control of the Democrats, to spell out the details of this plan. They must first answer a few questions: How much are the premiums for this public plan? And which hospitals and doctors will be in the network?

Elsewhere on the west coast, California Governor Gavin Newsom used his inaugural address to offer a wide range of health system reforms. Among them are a letter He sent the Trump administration to ask the federal government to provide new flexibilities that would allow a state to manage its own single-payer program.

Here's why. Medicare and Medicaid are programs administered by the federal government. The creation of a single state-wide health insurance plan requires significant changes to these programs – and this requires Washington's approval.

Newsom will almost certainly not have the approval of President Trump; Observers do not expect the one-time California effort to be feasible by 2021 at the earliest (and perhaps even later, if Trump is re-elected).

So, Newsom has also deployed short-term plans expand public coverage. It proposes to cover young undocumented adults through the Medicaid State Program, which would make California the first state to do so. He is also studying ways to reduce spending on prescription drugs by bringing together all government agencies to buy bulk drugs.

And across the country, in New York, Mayor Bill de Blasio wants to bring universal health care to America's largest city – or at least the message he wants uninsured New Yorkers to hear.

De Blasio unveiled a new plan this week According to him, this would ensure that every New Yorker, regardless of his ability to pay, would be able to see a doctor and have affordable medical treatment in the city's historic hospital system.

These are not single payer health care. Blasio's plan is essentially a much-needed injection of funds for troubled public hospitals in New York City: $ 100 million more per year. Through a program called NYC Care, any uninsured New Yorker is able to visit one of the 70 clinics in the hospital system and see a primary care physician. They will be charged, where appropriate, on a sliding scale designed to maintain care at an affordable price, although we have not seen the details yet.

"We hope people will know that they have access to a primary care physician and that they can start there," said Katie Robbins, director of the New York Health Campaign, rather than to go to emergencies.

Mitchell Katz, chief executive of the hospital system, oversaw the similar program launched in San Francisco 10 years ago. The San Francisco Healthy Plan is not the same as New York, but it has the same basic structure: uninsured residents could go to the city's clinics and get medical care at an affordable price for them .

The San Francisco program, as evidenced by this report 2011, has been largely judged a success. Three-quarters of the participants consulted a physician during their first year of registration, emergency room visits also declined, and preventable hospitalizations among the uninsured also declined.

Now, New York is building this experience with Katz at the helm.

"Giving people direct access to care is not the same as a right to full coverage," says Larry Levitt of the Kaiser Family Foundation. "But in a voluntary and fragmented insurance system like we do now, there will be people who fail, and a more organized and accessible safety net makes perfect sense for them."

Democrats test political ideas that could become national in 2021

These new proposals matter at two levels. First, programs that expand public health insurance will obviously have an impact on the beneficiaries of coverage. When Newsom, Inslee and Blasio talk about their ideas, they all talk about the importance of reducing the rate of uninsured people and ensuring that their constituents have access to medical services.

It is also important to think about how these plans could spread across the country. Democrats are at a time when they are vigorously discussing the future of health care. There are currently eight different plans to develop public insurance floating around Capitol Hill, and it is likely that other projects will be introduced when Democrats take control of the House.

States can serve as a test bed for ideas that Congress wants to debate. California, Washington and New York have strong Democratic majorities capable of implementing ideas that would remain deadlocked by the divided government in Washington. They can see how these programs work as they unfold in the real world and if the rest of the country wants to follow that example.

The history of the Affordable Care Act is particularly instructive here. In 2006, Massachusetts adopted the first expansion of health coverage in the country, which banned pre-existing conditions and forced all residents to buy health insurance.

This law led to a sharp decline in Massachusetts' uninsured insurance rate, which quickly fell to the lowest level in the country. This caught the attention of policymakers in Washington – and when President Obama took office in 2009, the Massachusetts model quickly became the backbone of his health reform proposal: the Affordable Care Act. He even called on some of the Massachusetts project architects to help him write and model his new national version.

A new national or urban plan could play a similar role in Washington's future health reform efforts – an opportunity to test an idea in a smaller setting and see if it works properly.